Basketball Coaches Without Boundaries

2010 INSTRUCTIONAL BASKETBALL CAMP REGISTRATION FORM

$35.00 Per Camper

Boys and Girls - Grades 1st to 5th

(Please complete a registration form for each individual)

Mail registration form and payment to BCWB, P. O. Box 3528, Frederick, Maryland 21705

Camper Name: _________________________________________________

Address: _________________________________________________________

Phone: __________________________________________________________

Phone 2: _________________________________________________________

E Mail: __________________________________________________________

Date of Birth: _____________________________________________________

Grade He/She is in during the 2009-2010 school year: _____________________

School: __________________________________________________________

Medical Problems?l: __________________________________________________________

T- Shirt Size Youth or Adult (i.e. Y-Small, A-Small): _______________________

Medical Release & Registration Agreement

The undersigned, parent/legal guardian of the player requesting league admittance, does hereby affirm that the applicant is in good health and suffers from no illness, disability, or condition that requires the taking of medication on regular basis unless that condition is disclosed and approved. Furthermore, the undersigned has no knowledge of any reason the applicant cannot participate in vigorous physical activity. The undersigned hereby expressly agrees to be responsible for any medical bills incurred in the treatment of any illness or accident. In the event of any such accident or injury, I hereby consent to allowing any of the league supervisors to procure any medical treatment deemed advisable on behalf of my child or ward without prior consent. I understand that, as a condition of admittance as a league participant, the undersigned, on behalf of all parents and guardians, and behalf of the applicant, hereby release Basketball Coaches Without Boundaries and all other employees or agents of the league from any and all liability in regards to injury or illness, either mental or physical suffered by the league participant during or related to the league by the person or entity against which the claim is made. By signing the signature line below you are completely aware and have full understanding of the advertised terms. I have read the above and agree to the league conditions:

Parent Signature: Parent Name (Print):

______________________________________________ ___________________________________________

Date : _______ Emergency Contact Information: _________________________ _______________________

Name Telephone Number